By submitting this completed form, I am requesting this information be entered into the database for the Tay Township Functional Needs Registry. The information in this registry will be used to alert public safety responders (police, fire and EMS) that an individual residing at this address has a disability that may hinder evacuation or transport. This will also notify them of premise information such as lock boxes, hidden keys etc. This information is confidential and will only be used in the event of an emergency.
Accomodation Notice: This form can be made available in an alternate format upon request.
REGISTRANT INFORMATION
EMERGENCY CONTACT INFORMATION
